Understanding Troubled Minds Updated Edition: A guide to mental illness and its treatment

2014

CHAPTER 1

The History of Mental Illness and its Treatment

Steady progress has been made towards scientific enlightenment and better treatment for the mentally ill. However, insights from the past remain useful. While psychiatry’s past is littered with the corpses of ineffective, and at times hazardous, treatments, certain progressive social approaches to mental illness may have been lost sight of and need revisiting. Thus, critical appraisal of contemporary enthusiasms is again demonstrated to be a useful function of the study of history. In the words of the philosopher George Santayana, ‘Those who cannot remember the past are condemned to repeat it’.

Attempts to understand and treat the mentally ill go back centuries. Name changes reflect the diverse ways in which mental illness has been regarded. For example, ‘lunacy’ is derived from the belief that people’s mental states deteriorated at full moon; ‘insanity’ from the Latin insanus, meaning unsound mind; and ‘psychiatric’ from the Greek words for soul, psyche, and healing, iatreia.

Possibly the earliest account of a disturbed mind is recorded in the Ayur Veda, a 3500-year-old Hindu text. A man is described as ‘gluttonous, filthy, walks naked, has lost his memory and moves about in an uneasy manner’. In the first Book of Samuel we read that King David simulated madness in order to gain safety: ‘And he changed his behaviour … and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard’. In the Book of Daniel we find a vivid description of King Nebuchadnezzar’s mental state: ‘And he was driven from men, and did eat grass as oxen, and his body was wet with the dew of heaven, till his hairs were grown like eagles’ feathers, and his nails like birds’ claws’.

The ancient Greeks went beyond mere description of madness. Their explanations of the causes centred about an imbalance of bodily humours or fluids. Hippocrates, in the fourth century BC, viewed it this way, but also invoked environmental, physical and emotional causal factors. The Greek physician Galen, who practised in Rome 600 years later, persisted with the concept of fluid imbalance, postulating that depression was caused by an excess of black bile (hence the term ‘melancholia’, from melan, black, and khole, bile), though he also took emotional influences such as erotic desire into account. Modern psychiatry conceptualises disturbances of mood in strikingly similar ways to those of the ancients. Indeed the term ‘melancholic features’ resurfaced in the twentieth century to cover the biological changes seen in depression.

During the Middle Ages, the monasteries preserved the view of madness as an illness and of those afflicted as blameless. At the same time, the more sinister belief that the principal cause of the troubled mind was possession by the devil prevailed. Sufferers were taken to sanctioned healers, usually priests or shamans (a practice still carried out today in some cultures).

People who failed to respond to such routine treatment might then seek out a celebrated expert. The case of Hwaetred, a young man who became tormented by an ‘evil spirit’, is a clear example. So terrible was his madness that he attacked others with his teeth; when men tried to restrain him, he snatched up an axe and killed three of them. Taken to several sacred shrines, he obtained no relief. His despairing parents then heard of Guthlac, a monk who lived a hermit life north of Cambridge. After three days of prayer and fasting Hwaetred was purportedly cured.

Sin was rarely seen as causing mental illness. Rather, it was a visitation from without, affecting even righteous people. A particularly harrowing period was the seventeenth century, when religiously inspired persecution of the mentally ill was justified by the clerical hierarchy, who designated them as witches. Fortunately, this coincided with the medical profession’s claim to exclusive practice of the healing arts, such as they were, and its withdrawal from former links with the priesthood. A new fairness in treatment of deranged people resulted both from the church’s emphasis on charity and medicine’s growing agreement that the cause of insanity was physically based.

Life before the Industrial Revolution has been portrayed as one of tranquillity, the countryside supposedly scattered with picturesque villages whose inhabitants tilled the fields, celebrated festivals and cared cooperatively for one another. The reality was otherwise. Thomas Hobbes, the social philosopher, described their lives as ‘solitary, poor, nasty, brutish and short’. The insane were depicted as ‘miserable individuals, wandering around in village and in forest, taken from shrine to shrine, sometimes tied up when they became too violent’.

Death by public drowning was once the not uncommon fate of mentally ill women branded as witches (from The Remarkable Confession and Last Dying Words of Thomas Colley, London, undated).

The late eighteenth century was a watershed in the history of psychiatry. The insanity of England’s King George III revealed society’s ambivalence to the mentally ill (vividly captured in the film The Madness of King George). In France, Philippe Pinel released the chains that had fettered the ‘lunatic’ for centuries, ushering in an unprecedented phase of benevolent institutional care. Moral therapy was the most significant advance of this era. It supplanted earlier physical treatments such as purging, bleeding and dunking in cold water. Moral therapy worked instead on the intellect and emotions, and was designed to achieve internal self-restraint and mental harmony. The approach was taken up with fervour by the Quakers who established the York Retreat; the humane movement was soon championed in the United States.

Literary descriptions of mental illness

An evocative description of mental illness by Honoré de Balzac appears in his novel Louis Lambert, published in 1832. The main character, a highly intelligent young man, becomes infatuated with a childhood sweetheart but once married plunges into a world of insanity. The narrator, a childhood friend of Louis, notes on seeing him:

… his body seemed to bend beneath the weight of his bowed head. His hair, which was as long as a woman’s, fell over his shoulders and surrounded his face, which was perfectly white. He constantly rubbed one of his legs against the other with an automatic movement which nothing could check, and the continual rubbing of the two bones made a ghastly noise. Beside him was a mattress of moss, laid on a board. He was a remnant of vitality rescued from the grave, a sort of conquest of life over death, or of death over life. Suddenly Louis ceased to rub his legs together and said slowly, ‘The Angels are white’.

Nikolai Gogol, the Russian novelist, published Diary of a Madman around the same time. Gogol himself was destined to succumb to what was probably severe depression, manifesting as pervasive guilt, social withdrawal, despair and finally death by self-starvation. The story paints a frenzied picture of madness and the final plea is heart-rending: ‘Mummy, save your poor son! Shed a tear on his poor battered head and look how they are tormenting him! Press your orphan boy to your breast! There is no place for him on earth! He is persecuted! Mummy, have pity on your sick little child!’

Guy de Maupassant, the French writer, recorded the essence of the disordered mind in a short story, The Horla, offering this vivid description:

I ask myself whether I am mad … doubts as to my own sanity arose in me, not vague doubts, such I have had hitherto, but precise and absolute doubts. I have seen mad people and I have known some who were quite intelligent, lucid, even clear sighted in every concern of life, except at one point. They could speak clearly, readily, profoundly, on everything, till their thoughts were caught in the breakers of their delusions and went to pieces. There, they were dispersed and swamped in that furious sea of fogs and squalls which is called madness … Was it not possible that one of the imperceptible keys of the cerebral fingerboard had been paralysed in me? … By degrees however, an inexplicable feeling of discomfort seized me. It seemed to me as if some unknown force were numbing and stopping me, preventing me from going further and calling me back.

Eventually the narrator comes to believe that he can fend off his persecutor only by setting fire to his house. But his torment persists to the final lines: ‘No—no—there is no doubt about it—he is not dead. Then—then—I suppose I must kill myself!’

The era of the asylum and advent of physical treatments

The sheer numbers of mentally ill people in burgeoning urban slums demanded action. An institutional solution emerged. Asylums (from the Greek word meaning refuge) were built in rural settings with the best of intentions, planned to be havens in which patients would receive humane care. In the serenity of the countryside, and through carrying out undemanding tasks, they could be distracted from their internal torment and find dignity far from the madding crowd. Daniel Defoe, the English writer, remained unconvinced: ‘This is the height of barbarity and injustice in a Christian country; it is a clandestine Inquisition, nay worse’.

Though conceived in a spirit of optimism, asylums tended to deteriorate into centres of hopelessness and demoralisation. They soon became overcrowded dumps. Institutions originally built for a few hundred people were soon holding thousands. Very few residents were discharged; many stayed for decades. Brutal oppression replaced anything that might have resembled treatment; malnutrition and infectious disease became rife. In the grim environment, people were shut away and forgotten. Family contacts were often lost, especially as the asylum was frequently at a distance from the patient’s home. Out of sight and out of mind, a loss of public interest and political neglect became the norms. A fascinating exception is the York Retreat in England, established by the local Quaker community.

The brooding building on the hill came to symbolise the fear of mental illness and the stigma with which it remains associated—alas, even to the present time. By the mid-nineteenth century, critics were voicing concerns that asylums had evolved into human warehouses in which mental illness inevitably became irreversible. The combination of powerless patients, hospitals run more for the convenience of staff than for the benefit of the sick, inadequate inspection by state bodies and lack of resources led at times to quite disgraceful conditions. Unwittingly, the spread of asylums also triggered the movement of psychiatry away from the mainstream of medicine. This regrettable divorce was reflected in the term ‘alienist’ for doctors who practised in the asylums. Attendants and medical staff were also often cut off from the rest of society in that they lived with their families in the hospital grounds.

The conditions are evocatively described in Henry Handel Richardson’s Australian novel, The Fortunes of Richard Mahony. We read of Richard’s decline, probably from neurosyphilis, which at that time afflicted a large proportion of mental patients. Towards the end of the novel his wife comes to visit him in the asylum:

She hung her head, holding tight … to the clasp of her sealskin bag, while the warder told the tale of Richard’s misdeeds. 97B was, he declared, not only disobedient and disorderly, he was extremely abusive, dirty in his habits … would neither sleep himself at night nor let other people sleep, also he refused to wash himself, or to eat his food … But she had to keep a grip on her mind to hinder it from following the picture up: Richard, forced by this burly brute to grope on the floor for his spilt food, to scrape it together and either eat it or have it thrust down his throat … she had heard from Richard about the means used to quell and break the spirits of refractory lunatics … There was not only feeding by force, the straitjacket, the padded cell. There were drugs and injections, given to keep a patient quiet and ensure his warders their freedom: doses of castor oil so powerful that the unhappy wretch into whom they were poured was rendered bedridden, griped, thoroughly ill.

Although such a decline was often the result of years of confinement, the concept of a degenerative process in the brain became widely accepted as a likely explanation and gained added impetus from the rise of pathology as a branch of medical science. The search for causes of mental illness in the brain proved fruitful in some areas, especially in identifying neurosyphilis and the neuropathology of Alzheimer’s dementia.

So compelling was the organic paradigm that all major forms of mental illness were assumed to be caused by a degenerative brain process. Thus, when the clinical syndrome of dementia praecox was mapped out through the careful scientific work of the great German psychiatrist Emil Kraepelin, it was assumed that it also had a degenerative basis and that the outcome was inevitable decline. So too with the Swiss psychiatrist Eugen Bleuler, who in 1911 renamed dementia praecox with the term we use today, schizophrenia. Though most understanding towards his patients, Bleuler propagated the idea that they could never fully recover. This was undoubtedly related to the fact that many of his patients were hospitalised for decades without effective treatment.

Great and desperate cures

In the asylum, too, psychiatry turned into a medical discipline. The accumulation of thousands of patients provided the first opportunity to study mental illness systematically. But the priority was the suffering of overwhelming numbers of disturbed patients. Psychiatrists grasped for ‘great and desperate cures’. Henry Rollin, an English psychiatrist and medical historian, captures the intense zeal:

The physical treatment of the frankly psychotic during these centuries makes spine-chilling reading. Evacuation by vomiting, purgatives, sweating, blisters and bleeding were considered essential … There was indeed no insult to the human body, no trauma, no indignity which was not at one time or other piously prescribed for the unfortunate victim.

Treatments were sometimes based on rational grounds. Malaria therapy, for instance, was launched as a treatment for syphilis affecting the brain by the Viennese psychiatrist Julius von Wagner-Jauregg in 1917, earning him a Nobel Prize ten years later. The rationale for inducing a high fever using the malarial parasite was the heat sensitivity of the spirochete that caused neurosyphilis. Von Wagner-Jauregg may have had a point; substantial improvement occurred in the nine cases he reported on a year later. But the hope that it would be equally effective for other forms of psychosis was soon dashed. The wished-for panacea was not to be. In any event, malarial therapy was hazardous and difficult to apply.

Insulin coma therapy was introduced by Manfred Sakel in the 1930s in Vienna and was soon being used in many countries to treat schizophrenia. An insulin injection was administered six days a week for several weeks, producing a state of light coma lasting about an hour, because of reduced glucose reaching the brain. Many years later, an investigation carried out in the Institute of Psychiatry in London, a leading research centre at the time, showed conclusively that the coma itself was of no therapeutic value. The benefits noted were probably attributable to the conscientious attention given to the patient by dedicated staff over an extended period.

The first widely available and effective physical treatments for mental illness were developed in the asylum. The discovery in 1938 of electroconvulsive therapy (ECT) by Cerletti and Bini, two Italian psychiatrists, led to a dramatically effective treatment for people with severe depression. ECT was eagerly adopted in practice but its history illustrates a typical pattern of treatment in psychiatry, where unbridled early enthusiasm is later tempered by a protracted process of scientific evaluation. Exactly the same can be said of psychosurgery—or surgical procedures—on the brain to modify psychiatric symptoms. This was pioneered in 1936 by a Portuguese neurologist, Egas Moniz (another Nobel Prize winner in the field of psychiatry) and a surgeon, Almeida Lima. It has been a source of controversy ever since. Regrettably, the negative image of both treatments still hampers their usefulness for carefully selected patients (see Chapter 18).

A momentous breakthrough was the report in 1949 by John Cade, an Australian psychiatrist, of lithium as a treatment for manic excitement. The lithium story is an illuminating one in revealing how the incorporation of a new medication into psychiatric practice is not always accomplished smoothly. Cade was not the first person to detect the potential benefits of lithium for the mentally ill. In the 1870s, two American clinicians separately prescribed it for ‘nervous excitement’. A Danish psychiatrist then described its role in severe depression in 1894. All these initiatives were ignored for decades, in fact until Cade’s observations. Yet another long period followed before studies were undertaken, again in Denmark, to examine the role of lithium to prevent the recurrence of severe changes of mood (its principal application in contemporary practice). The definitive research report was only published in 1967. Notwithstanding, two leading British psychiatrists expressed, unjustifiably, their disdain for lithium, emphasising the poor scientific methods that had been deployed in studying it and the dangers in its use.

Major tranquillisers were discovered fortuitously in 1953 when an antihistamine noted to calm patients undergoing surgery also reduced the torment of psychotic patients, but without making them sleepy. Shortly after this, Nathan Kline discovered that a drug being tested for its effect in patients with tuberculosis had anti-depressant properties—the forerunner of medications for depression. All these drugs radically transformed the practice of psychiatry (see Chapter 18).

The advent of psychological therapies

A very different aspect of psychiatry arose in the 1890s, independently of the asylum. Concerned with neurotic illnesses, the new treatment grew chiefly out of neurology but was also influenced by a scientific interest in hypnosis and the unconscious. Sigmund Freud conceived of a dynamic model of the mind in which, through the mechanism of repression, painful or threatening emotions, memories and impulses are prevented from escaping into conscious awareness. Psychoanalysis grew to become an integrated set of concepts about normal and abnormal mental functioning and personality development, and spawned a novel method of psychologically based treatment. Psychoanalysis has emerged as a major theoretical underpinning of contemporary psychotherapies, and its influence has spread far beyond psychiatry, as evidenced by the number of Freud’s ideas that have entered everyday thinking (see Chapter 19).

Both world wars profoundly influenced the field. The high incidence of ‘shell shock’ in World War I drove home the lesson that mental illness could affect not only those genetically predisposed, but even the supposedly robust. It soon emerged that anyone exposed to traumatic experiences could suffer psychiatrically as a consequence. A positive outcome from World War II was the development of techniques for screening large numbers of recruits, these providing a picture of the widespread prevalence of emotional problems among young adults. The need to treat large numbers of psychiatric casualties led to the development by military psychiatrists of group therapy. Given that group members were not only helped by the therapist but also learned from one another, group therapy had the effect of breaking down the rigid hierarchy of psychiatric institutions. It also paved the way for the so-called therapeutic community, based on the idea that an entire ward of patients could in itself be an integral part of treatment.

The idea of deinstitutionalisation began to gather pace in the 1960s, driven by a burgeoning civil rights movement. Asylums, an influential book at the time by sociologist Erving Goffman, containing his minute observations of the sense of oppression experienced by patients in these ‘total institutions’, was also a catalyst for their closure. Hundreds of thousands of long-stay patients have been transferred to alternative accommodation since the 1960s, a process still in progress. Specialist care in the setting of the community is becoming the norm, at least in more wealthy countries.

The contemporary scene

I grab every opportunity to instil in all my students the sense of excitement I feel about the contemporary state of my field. So many developments are taking place in every sphere, whether it be new technology to study how the brain works, new treatments—both physical and psychological—or innovative systems of delivering mental health care (for example, mother–baby units). Consider medications to illustrate. A new class of anti-depressants, the selective serotonin reuptake inhibitors (SSRIs), has enabled us to relieve depression with far fewer unpleasant side-effects and with a vastly reduced risk of death through overdose than their predecessors. The older anti-psychotics have been replaced by a new generation of medications that do not produce the former’s serious purposeless bodily movements. A massive effort is being devoted to the production of effective but safe medications for all conditions. Alzheimer’s disease, for example, has long been regarded as untreatable, with progressive deterioration the inevitable course. Even here, the decline in cognitive and social functioning may be delayed in a proportion of patients with the use of certain drugs.

Psychological therapies, too, have become more refined so that their effectiveness can be measured in research studies designed in a similar way to drug trials. Psychoanalytic psychotherapy has moved towards briefer forms of treatment that focus on more circumscribed problems. Cognitive-behavioural therapy (CBT) has emerged as an effective form of treatment. Initially devised to treat depression, it is also finding a place in the treatment of such conditions as anxiety, panic attacks, phobias and hypochondriasis. Combining SSRIs and CBT for depression has been repeatedly shown to lead to superior outcomes compared with either treatment given on its own. Family therapy has evolved substantially, especially in the area of child and adolescent psychiatry, as a way of treating problems which, though they are identified in one person, are actually an expression of maladaptive relating that pervades the entire family.

There is an accelerating pace of change in how mental health services are provided. Many governments have accepted the view that most resources should be placed in the community, and that admission to hospital should be brief, lasting on average a couple of weeks, in contrast to the lengthy periods of the past. Emergency assessment is carried out largely by community-based teams; other professional teams have evolved to assist more disabled patients.

There has been a steady expansion of the numbers of general hospital psychiatric units. These provide a much less stigmatising setting than a psychiatric hospital, and are usually situated much closer to patients’ homes. Enduringly ill patients may be cared for in supervised homes in the community rather than in long-term wards of psychiatric hospitals, most of which have been closed or greatly reduced in size.

Impressive as this sounds, community-based care is not problem-free. To a large extent it has been driven by an ideology that, although differing in crucial ways, nonetheless resembles that associated with the rise of the asylum. The creation of the asylum in the countryside was based on a set of values driven by nostalgia for a ‘natural’ place of healing. The concept backfired because it isolated the mentally ill, and the costs involved were huge.

Today, the community is positively valued and institutions are derided. But parallels prevail. The same search for a natural place of healing is evident—not the countryside this time but the human community in cities and towns. Unfortunately, just as the asylum idea backfired so too has that of community-based care. The mentally ill have been isolated yet again, with many of them homeless and living in temporary, often unsuitable accommodation such as a boarding house in a poor area.

Partly as a reaction to the asylum as human warehouse and, later, to defects of community care, a consumer movement has been gathering momentum since the 1960s, to represent people who suffer from mental illness and their families. This network of support for its members has taken on a prominent advocacy role that has influenced the shape of psychiatric care, especially the development of local community-based services and the empowerment of the mentally ill themselves. At the same time, the plight of the mentally ill is raised more easily in the social and political arena.

A mixed picture

Governments are increasingly recognising the social and financial costs of mental illness. The Global Burden of Disease, a major study commissioned by, among others, the World Health Organization, has had a huge impact by showing that in 2020 mental illness will be a major cause of continuing disability. In terms of specific conditions, heart disease will rank first, depression second. These predictions have noteworthy implications for health economists and politicians. In many countries there is a glaring disparity in the proportion of the health budget dedicated to mental illness compared with other illnesses. The challenges to create a just system are immense. While an optimal system of mental health care remains elusive, ethical principles concerning decent care—such as those contained in the 1992 United Nations Charter on the Rights of Mentally Ill People—have prodded some governments to carry out reforms.

Mentally ill people and their families continue to face the ordeal of stigma; psychiatric illness is still seen as shameful. Fear associated with the history of the asylum is an enduring influence. People may hesitate to seek medical help or accept referral to a psychiatrist. Stigma also affects recovery, since the prejudice of others and the person’s own negative expectations affect opportunities for work and social integration. The tabloid media aggravate the situation by running sensationalist stories about the danger to society of people with mental illness roaming around in the community. In fact, they are no more likely than the general public to act violently. On the contrary, they are more often victims of aggression.

These, sadly, are indisputable facts, and call out for attention. Equally indisputable, however, are the impressive strides that we are making in the twenty-first century. I have already mentioned some of these accomplishments and will highlight others throughout Understanding Troubled Minds, particularly in the two chapters on treatment. Astonishingly, more has been achieved in the past fifty years than during the entire twenty-four centuries since the ancient Greeks inaugurated the systematic study of the disturbed mind. We can be quietly confident that scientific research as undertaken now in many countries will lead to considerable progress and to the development of still more effective treatments in the years to come. However, we must be patient. Scientific progress tends to be incremental; the ‘Eureka, I have it’ discovery is rare. In the meantime we must be vigilant so that we do not repeat past mistakes. In this regard, the ethical dimension will always be as central as the scientific and the clinical.

CHAPTER 2

Making Sense of a Life

In 1879, a 26-year-old man began to evangelise with great fervour, gave away all his possessions, lived in a hovel, wore shirts made of sackcloth, and deprived himself of the basic necessities of life. A decade later, he sliced off a bit of his left ear and gave it to a prostitute saying, ‘Keep this object carefully’.

How can we make sense of such unusual behaviour? In the practice of psychiatry, we attempt to do so by using what are usually referred to as perspectives. Several are available but two stand out—understanding and explanation. In this chapter, the tragic story of one of the greatest artists of all time, Vincent van Gogh, is used to show how these perspectives help us to do our job.

In day-to-day life, all of us try to make sense of our own behaviour and that of others. We give little thought to how we do this but are quite adept at the task, enough to feel we understand what makes ourselves or others tick. One vital means we use in trying to understand other people is empathy (from the Greek em, into and pathos, feeling); we place ourselves in the other person’s shoes and try to imagine what they are experiencing. The information we draw on includes their statements about what they believe, feel, intend, wish, and so on, and the reasons they give for their psychological functioning and behaviour. We also consider their past experiences, customary ways of feeling and thinking, and current circumstances. We then arrive at a ‘commonsense’ understanding of how it is that a person acts in a particular way.

By using empathy and related understanding, we tackle the world of other people from the inside and seek meaning in their behaviour. A specific life event, say failing an exam, may well have different meanings for different people depending on their previous experiences, future aspirations, competing interests, and the like. Each of us can determine, through empathy and related understanding, how one psychological event stems from another. For example, we can appreciate that a hardworking student who is intensely anxious not to disappoint her parents and teachers by doing poorly in her favourite subject, feels utterly devastated on failing even though this was due to her misreading of a pivotal exam question because she was in the midst of a severe bout of flu but had stubbornly insisted, against all advice, that she was fit enough to take the exam. Consider another student who is entirely sanguine about failing; in his case he has never found the subject appealing, had been planning to drop it the whole semester, and now feels a sense of relief that he has found a way to justify his decision to abandon studying the subject.

The capacity to empathise with and understand another is a marvellous asset generally and an indispensable skill, but it has its limitations. When a person’s experience or behaviour lacks any sense of meaning and there are no clear connections between psychological events, we have to resort to looking in from the outside. For example, if a person is adamant that they are being hounded by the devil, we will regard them as deluded if they hold that belief with absolute conviction and without adequate reason, and resists obvious evidence that the belief has no foundation; these are the specific features of delusions regardless of what they are about. The person could be convinced that they are being hounded by the CIA or all their teachers or the United Nations; the content is not relevant to determining what is going on in them.

This explanation-based perspective, which focuses on the form of an experience or behaviour and not its content, enables us to diagnose a specific disorder; this in turn informs them about its cause, likely outcome and what treatments are bound to be effective. Use of the perspective has resulted in pivotal discoveries about the nature of mental illness—distinguishing between various types of illness, the role of genetics, the link between brain dysfunction and abnormal mental states, and helpful treatments.

Let us now return to Van Gogh to see how understanding and explanation are used by the clinician. Why select him? Not only because he was a great and well-known artist but also because his life is richly documented through letters he wrote and the meticulous descriptions by others. We start with the major dates and events in Van Gogh’s life shown below.

Vincent Van Gogh’s life

Van Gogh grew up in an austere Dutch middle-class family led by a pastor father of limited talent who was assigned to peripheral parishes. His mother was a strong woman, unusually gifted in writing and painting. Two professions dominated in the family—the clergy and art-dealing. The family tree reveals a striking presence of mental illness. Van Gogh’s uncle, also named Vincent, was subject to nervous complaints, frequently fleeing to the southern sun to recuperate. A family history of epilepsy existed on his mother’s side.

Vincent Van Gogh’s life history

Accounts of Van Gogh’s childhood are inconsistent. Some suggest an unremarkable child whereas others portray him as solitary, ‘not like other children’, and estranged from his family. He was passionate about nature. He briefly attended the village school and then from eleven to sixteen was educated in boarding schools. His progress was unexceptional, but he read prolifically and had a knack for languages.

Despite excellent connections, his career was erratic. Through the mentorship of his wealthy uncle, he became an apprentice art-dealer. The prospect of inheriting his uncle’s mantle was obvious. However, after rejection in love by his landlady’s daughter, he lost interest and became fanatically religious. Attempts to study theology in Amsterdam and become an evangelist were unsuccessful, largely due to his provocative behaviour. Nonetheless, he was appointed as a lay preacher in a poor region of Belgium. His extreme selflessness soon led to his dismissal. After almost a year of miserable solitude, he announced his intention to become an artist. He returned to his parents’ home for two years and then lived with his brother Theo (who had become a successful art-dealer like his Uncle Vincent). Van Gogh’s only close relationship then was with his brother, although it was not free of tension. They corresponded frequently and by 1886 he was entirely financially dependent on Theo. Later, he moved to Arles in Provence and finally to Auvers-sur-Oise, just outside Paris.

Vincent Van Gogh’s family tree

Van Gogh’s four key relationships with women all ended in humiliation. In London a passionate proposal of marriage was rejected by Eugenie Loyer, who was already engaged to another. He fell in love with Kee Voss, a widowed cousin, but again she did not reciprocate; his persistence resulted in much family bitterness. The following year he formed a liaison with Sien, an unmarried, pregnant prostitute. She was already the mother of a 5-year-old girl. Despite his care for her, Sien lapsed into her old ways and he felt no alternative but to leave her. Finally, he was the subject of an infatuation of a lonely spinster ten years his senior. Her family bitterly disapproved of Van Gogh. In the ensuing crisis she attempted suicide and was sent to a sanatorium.

Other relationships also collapsed. The most crucial was that with Paul Gauguin in Arles, where the atmosphere between them was ‘electric’ and culminated in Gauguin’s departure. Van Gogh became severely disturbed, complaining that he was ugly, coarse (‘as thick skinned as a wild boar’) and demoralised. As he put it: ‘a terrible discouragement gnawing at one’s very moral energy … fate seems to put a barrier to the instincts of affection, and a flood of disgust rises to choke one’; ‘I am a prisoner in I do not know what horrible, horrible cage’.

On the other hand, Van Gogh felt remarkably energetic at times: ‘The emotions are sometimes so strong that one works without knowing one works’; ‘Ideas for my work come to me in swarms’; ‘I go on like a steam engine at painting’; ‘I only count on the exaltation that comes to me at certain moments, and then I let myself run into extravagances’. But after bursts of energy, melancholy invariably followed. Then he neglected his appearance, exposed himself to the elements in Herculean hikes, sometimes slept in the cold and often neglected to eat. He also drank heavily: ‘If the storm gets too loud, I take a glass too much to stun myself.’

His medical and psychiatric history

Suffering from gonorrhoea, Van Gogh required a three-week admission to hospital in 1882. He may also have suffered from syphilis in 1886. He often complained of physical symptoms including stomach trouble, anorexia, dizziness and headaches.

At least seven episodes of severe mental disturbance occurred between 24 December 1889 and mid-April 1890. The first followed his acrimony with Gauguin in Arles, when he sliced off part of his left ear and deposited it with Sien. Most attacks began abruptly, with confusion, rambling talk, frightening hallucinations and religious-type delusions, and others of being poisoned. He acted aggressively without provocation. He made frenzied attempts to eat his paints and to drink kerosene. He later described these experiences as ‘frightening beyond measure’ and the thought of recurrences filled him with a ‘fear and horror of madness’. There were associated ‘moods of indescribable anguish’, and he was sometimes observed to sit immobile for many hours. He voluntarily spent a year in a mental asylum, although he remained productive much of the time. Finally, he committed suicide at the age of thirty-seven.

What can we make of all this?

We will see in Van Gogh’s story unusual behaviour that might prove understandable, but also aspects better accounted for by an unravelling of its causes. His mood disturbances, the cutting of part of an ear, the psychotic episodes and his suicide are the subjects of particular interest.

Let us start with his mood. From the age of twenty Van Gogh suffered from swings of mood, predominantly depression but also excitement. In an effort to understand these, various psychological interpretations have been proposed. One biographer suggests that the key factor was domination by the stillbirth of his older brother Vincent, one year to the day before his own birth. His mother continued to grieve the loss and proved unable to devote her affections to the new child. He had to compete with an idealised lost child whose tomb he saw every day in the adjacent graveyard. This led to a profound sense of being unloved as well as unlovable, and a sensitivity to rejection. These sentiments were later played out in, and reinforced by, his unsuccessful love affairs. The failed relationships were followed by depression typified by self-punishment and estrangement from an apparently hostile world. Nonetheless, he still craved intimacy, but made intolerable demands on others; in effect he sought an unreserved love that he felt had been denied him earlier. He sought solace in a loving God, which required further suffering through self-denial and service to others. In this manner he could also give to those rejected like him the love he had never himself received. Van Gogh’s estrangement from his family is further supported by an absence of affectionate remarks about his mother in his letters.

He began to identify with Christ, who also suffered, was misunderstood, and dedicated to the oppressed. This identification offered him the comforting possibility of remaining aloof from mankind yet eventually of being universally loved. The liaison with Sien can be understood as a consequence of his poor self-regard, but she was also his Mary Magdalene, who would be transformed by compassion into a good woman. He rejected the conventional church and its hypocritical ‘Pharisees’, like his father. Periods of exaltation and frenzied work accompanied spiritual labours. Finally, his decision to become an artist represented a fusion of his, and his family’s, spiritual and artistic heritage. His intense immersion in his paintings, often accompanied by a numbing of his senses through starvation, exposure, exhaustion and alcohol, acted to ward off distressing feelings.

This interpretation, based on understanding, clarifies many aspects of Van Gogh’s personality but seems inadequate to account for his profound mood swings. At times he was oblivious to everything around him, stared bleakly into space, and ceased to eat. At other times his mind was seemingly in tumult, he dressed outlandishly, and talked and laughed embarrassingly; then he worked frenetically at strange projects, such as a simultaneous translation of the Bible into four languages. Van Gogh described his moods as sudden ‘unaccountable but involuntary emotions’. Others did not doubt that he had at these times passed from eccentricity to insanity.

The psychiatrist would now turn to the explanatory perspective—proposing a biological basis for his vulnerability to mood swings and, at times, clear-cut manic-depressive illness. His experiences and behaviour are consistent with typical features of what psychiatrists recognise readily as depressive and manic episodes. Genetic factors may have played a predisposing role, while unhappy events and physical ill-health were no doubt triggers.

Van Gogh’s mutilation of his ear is perhaps the most tantalising episode. None of the many interpretations fully accounts for this bizarre act. A psychotic illness is the likely explanation for the form his mental state assumed. It was probably sparked off by heavy consumption of absinthe (which contained a neurotoxin known to be associated with mental disturbances). Van Gogh’s poor nutrition and physical self-neglect may also have contributed.

We must consider the timing and the content of his madness as well as its form. His vulnerability was readily manifest in his deteriorating relationship with Gauguin. The weather was miserable and the two spent a number of enforced days in close proximity. Christmas was always a dangerous time. Vincent probably also knew about Theo’s forthcoming marriage, and could see the risk of losing his only real source of support. Immediately before the episode he had quarrelled with Gauguin, throwing a glass of absinthe at him, and later he was reported as having threatened him with a razor. Gauguin, like so many others, had ‘betrayed’ him. In guilt, Vincent directed his anger inwards, mutilating himself.

Why the ear and why present it to a prostitute? Several possible and plausible explanations come to mind. Bullfights, a popular pastime in Arles, culminated in the ear being sliced from the vanquished animal by the toreador to be presented to his favourite lady. Stories about Jack the Ripper’s dismemberment of his prostitute victims, sometimes involving an ear, appeared in the local paper at the time. Van Gogh was much preoccupied with the story of Christ in the Garden of Gethsemane, and destroyed two canvasses on this subject because they frightened him. In the episode of betrayal of Christ, Peter had cut off the ear of Malchus, a servant of the high priest, who had come to seize Christ.

Why the psychotic episodes?

There were several sources of intense stress in Van Gogh’s life at the time of his descent into madness. The threatened loss of Theo’s support, undivided until then and on which he was entirely dependent, was pre-eminent. Between January and April 1889, Theo had become engaged, married and an expectant father in rapid succession. Seeking solace in religion is not surprising given his past inclinations in that direction, but his religious ideas then were quite bizarre, totally beyond the comprehension of others (and, in retrospect, of himself). Eventually, he felt unable to look after himself and took to the suggestion of a period of asylum. Psychiatrists would examine the form of Van Gogh’s breakdowns in terms of our accepted classification of mental disorders. A dysfunctional brain is possible given his confusion, loss of memory and the relatively brief duration of the psychotic episodes. Alcohol, the absinthe he consumed, also may have contributed to his mental state.

The suicide

What about Van Gogh’s mental state at the time of his suicide? He continued to be buffeted by melancholia in Auvers. A month before he shot himself, he wrote: ‘My life is threatened at the very root, and my steps are also wavering’. His painting, Crows over the Wheatfields, reflects evil foreboding. Fear of losing his sanity again plagued him. He had lost faith in his doctor and described him as being as sick as himself. There were inexplicable explosions of anger directed at him, during one of which the doctor feared that Van Gogh might use his pistol upon him.

The threatened loss of Theo’s support had become more urgent. Theo then had a child with the perhaps ominous name of Vincent who, to make matters worse, had fallen ill. Theo’s own health was declining, he had money worries, and he was considering quitting his job. Although Van Gogh repeatedly begged Theo to spend his vacation at Auvers rather than in Holland, Theo declined. Van Gogh had on several occasions declared that his ‘life or death’ depended on Theo’s help. He could not easily express his resentment, and it is understandable, particularly in the light of previous self-destructive acts, that he turned his hostility inwards.

For the first time, Van Gogh was praised for his paintings. His response shows how events desirable to one person may disturb